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APPLICATION FOR PERMIT V, SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZ EL T ON AVE. STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/of install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 37?71-r- �OLEYhl&R City 5S_iVr_KnN Lot Sizerd A(9I F.�.5 PM Owner's Name n�11/ aeq -. Address Phone i ContractorGQ UtQZS�e 1)A?IL.1-1 Arr Address rS icense No,121,2� Phone 6 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 1, DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK L__ SEWER LINES DISPOSAL FLD.7,j:;f!!7-PROP. LINE FOUNDATION " AGRICULTURE WELL OTHER WELL -- PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 12 Dia. of Well Casing J-01Domestic/Private �4-Gravel Pack ❑ Tracy Type of Casing. "VC 16a PS/ __ __ Specifications M Public 1-1 Other ",Delta Depth of Grout Seal : Type of GroutBE/VTIJ/y=_ 1 1 Irrigation 6a-Approx. Depth I 1 Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction $ Well Diameter __-_ Sealing Material Itop 50') r — f Depth JZE Filler Material {Below 501 R- _T,91!!'1 F TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 1 DESTRUCTION l 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal • Distance to nearest: Well foundation Property Line G LEACHING LINE ❑ .No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l 1 Depth Size Number CX SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and i rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to becomesubject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature I certifies the following: "I ce ify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applic m st fo all that inspections. Complete drawing on re reside. Signed X Title: date: FOR DEPARTMENT USE LY r 'Q ? Application Accepted by Date I� � U Area Pit or Grout Inspection by //i5;___Date '?2 Final Inspection by Date Additional Comments: Q Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BYPATE PERMIT'NO. INFO j� CASH a.EH 13-24(REV.i/n 5 e 1 U 11; gq 4 -4 F EH 14-2B